The Panel on Treatment of HIV in Pregnancy and Prevention of Perinatal Transmission (the Panel) updated the Recommendations for the Use of Antiretroviral Drugs During Pregnancy and Interventions to Reduce Perinatal HIV Transmission in the United States.

The clinical guidelines for infant feeding now support shared decision making and clarify breastfeeding options for people with HIV on antiretroviral therapy with sustained undetectable viral load (levels of virus in the blood). Additional updates include revised and reorganized content and some revised section titles. Highlights from the updated sections are summarized below:

Pre-Exposure Prophylaxis (PrEP) to Prevent HIV During Periconception, Antepartum, and Postpartum Periods

• This section was updated in accordance with the current Centers for Disease Control and Prevention guidelines for HIV PrEP.

Antepartum Care for Individuals With HIV

• This section, formerly titled General Principles Regarding Use of Antiretroviral Drugs During Pregnancy, was revised to focus on pregnancy-related care and Table 4. Antepartum Screenings and Assessments for Pregnant People With HIV was added.

Recommendations for the Use of Antiretroviral Drugs During Pregnancy: Overview

• The Panel has reorganized and revised content to provide a comprehensive overview on the individualized selection of antiretroviral (ARV) drugs and recommendations for the use of ARV drugs during pregnancy, with links to updated scenario-specific content in other sections and Appendix C: Antiretroviral Counseling Guide for Health Care Providers.
• The Panel points out that pregnancy, lactation, and the potential for pregnancy should not preclude the use of drug regimens that would be chosen for people who are not pregnant, unless adequate drug levels are not likely to be attained in pregnancy or there are known adverse effects that outweigh potential benefits (AIII).

Use of Antiretroviral Drugs to Prevent Perinatal HIV Transmission and Improve Maternal Health

• This new section outlines core components and associated data about the use of ARV drugs before and during pregnancy to improve maternal health and prevent perinatal HIV transmission, including ARVs for newborns with perinatal HIV exposure.

People With HIV Who Are Trying to Conceive

• This new section was added to provide a short overview about recommendations regarding ART for people who are trying to conceive.
• The Panel recommends that the use of contraception, regardless of type, should not be required to initiate or continue ARVs that would otherwise be recommended for an individual patient, even if there are limited data in pregnancy (AIII).

People With HIV Who Are Taking Antiretroviral Therapy When They Become Pregnant

• The Panel recommends that pregnant people who present to care on long-acting injectable CAB and RPV during pregnancy should be counseled about limited data. The Panel now recommends that clinicians and pregnant people reach a shared decision about continuing this regimen with frequent viral load monitoring or switching to one of the Preferred or Alternative three-drug ARV regimens (CIII).

Table 6. What to Start: Initial Antiretroviral Regimens During Pregnancy for People Who Are Antiretroviral-Naive

• The table was revised to reflect updated Panel recommendations and to list the advantages and disadvantages of ARV combinations and regimens.

Table 7. Situation-Specific Recommendations for Use of Antiretroviral Drugs in Pregnant People and Nonpregnant People Who Are Trying to Conceive

• The Panel now recommends raltegravir (RAL) and ritonavir-boosted atazanavir (ATV/r) as Alternative rather than Preferred ARVs for use in pregnancy and for people who are trying to conceive.
• Although there are insufficient data about the use of BIC and DOR in pregnancy, the Panel recommends that pregnant people who present on these regimens with a suppressed viral load may continue their current treatment with frequent viral load monitoring or consider switching to an ARV regimen that is recommended for use in pregnancy.

Teratogenicity

• The Panel recommends that pregnant people with HIV should not delay initiating ART due to concerns about teratogenicity with first-trimester exposure (AIII).
• Table 8. Drug-Specific Risk Assessment by the Antiretroviral Pregnancy Registry was added to provide an overview of risk assessment across drugs.

Early (Acute and Recent) HIV Infection

• For pregnant people with early HIV infection who have previously used long-acting CAB as PrEP, the Panel recommends initiating ART with a ritonavir-boosted, darunavir-based regimen pending the results of genotype testing for integrase strand transfer inhibitor–resistance mutations (AII).